Appendix E: HCBS Spend-Down Notice Text

Eligible for HCBS in a Monthly NMP Spend-Down Category (PA/PJ/PM 21):

You qualify for Medical Assistance (MA) and payment of Home and Community Based Services (HCBS) in the __________ Waiver from _____ to _____.  You qualify for these benefits with a “monthly spend-down”.  This means you must incur $_____in medical expenses each month to be eligible for the rest of the calendar month. See the Spend-down section for more details on what medical expenses were used. A MA benefit card (PA ACCESS card) will be sent to you unless you were given one before.

The service provider will notify you when your HCBS will begin.

55 Pa. Code §§ 141.71, 178.1, 181.1, 181.13

Eligible for HCBS in an Ongoing NMP Spend-Down Category (PA/PJ/PM 22):

You qualify for Medical Assistance (MA) and payment of Home and Community Based Services (HCBS) in the __________ Waiver. You qualify for these benefits because you have medical expenses that are used to “spend-down” your income. See the Spend-down section for more details on what medical expenses were used. A MA benefit card (PA ACCESS card) will be sent to you unless you were given one before.

The service provider will notify you when your HCBS will begin.

55 Pa. Code §§ 141.71, 178.1, 181.1, 181.13

Eligible for HCBS in a MNO Spend-Down Category (TA/TJ 22):

You qualify for Medical Assistance (MA) and payment of Home and Community Based Services (HCBS) in the _________ Waiver.  You qualify for these benefits because you have medical expenses that are used to “spend-down” your income. See the Spend-down section for more details on what medical expenses were used. A MA benefit card (PA ACCESS card) will be sent to you unless you were given one before.

The service provider will notify you when your HCBS will begin.

55 Pa. Code §§ 141.71, 178.1, 181.1, 181.14

Updated March 12, 2012, Replacing December 2, 2005